What Is Medical Necessity? Las Vegas Recovery Center

When dealing with third party payment in the field of mental health and chemical dependency treatment there have been great misconceptions and misunderstandings of what the insurance companies will actually cover. When contacting their insurance provider, prior to entering treatment, clients are told that they have a benefit for 30 to 90 days of treatment, but that the verification of benefits is not a guarantee of payment. It is based on the “medical necessity” for that level of care, and in order to authorize treatment a client must meet their insurance company’s criteria. In other words, just because a client has coverage doesn’t mean they will receive their full benefits. The standard of “medical necessity” is very similar for most insurance companies. Initially, when a client’s case is reviewed, the focus is on their immediate state. They are checked to see if there is any impending danger from withdrawal, or if they will be a harm to themselves. Throughout treatment, the client’s progress is frequently reviewed to ensure that the they continue to meet the requirements of “medical necessity.” This concurrent review is used by the insurance company to determine when the client has the ability to succeed at a lower level of care. The insurance company’s psychiatric reviewer/peer clinical reviewer is used to make this evaluation, and will recommend when the client should “step down.” If Las Vegas Recovery Center feels the client needs a higher level of care than deemed by the insurance company, we will begin an appeal process on their behalf. Achieving more time for our clients is one of our highest priorities, but unfortunately is not guaranteed. Below you will find the definition and guideline for “medical necessity or “medically necessary” that a majority of insurance companies use when evaluating clients coverage. According to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(Washington, DC, American Psychiatric Association, 1994).

“Medically Necessary” or “Medical Necessity” shall mean health care services that a medical practitioner, exercising prudent clinical judgment, would provide to a Covered Individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Individual’s illness, injury or disease; and (c) not primarily for the convenience of the Covered Individual, physician, or other health care provider; (d) and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Individual’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors.

Inpatient Acute Detoxification

In order to meet criteria for this level of care, typically the covered individual’s symptoms must meet the diagnostic criteria of ICD-9 Substance Dependence diagnosis or DSM axis I. This is the criteria most insurance providers use when evaluating a covered individual for Inpatient Detoxification. Criteria:

Individual must be showing signs of withdrawal including seizure, tremors, vomiting, hallucinations, confusion, disorientation, and unstable vital signs.
Given a blood or urine drug screen after being admitted.
Their substance abuse and medical issues are posing as a life threatening issue.
Danger to themselves and others.

Qualifications:

Client must be meeting with a physician a least once a day.
Under 24 hour watch by trained nursing staff including RN or LVN/LPN.
Client is still being administered detoxification medications by medical staff.
Individual is not stable enough to move to the next level of care.

Las Vegas Recovery Center offers this level of care Typically once a covered individual no longer meets just one of these qualifications the insurance provider no longer has to authorize services.

Inpatient Acute Rehabilitation (Inpatient Rehabilitation)

This level of care is one step below detoxification and has its own set of guidelines. In order to receive initial authorization and continued authorizations, clients must meet the following: Criteria:

The individual no longer needs detoxification.
The individual is still medically monitored with a 24 hour medical staff on site including RN, LVN/LPN.
Individual has a severe psychiatric or co-morbid medical disorder.
Individual has expressed a desire to work towards recovery and rehabilitation.

Qualifications:

Individualized treatment plan has be established.
Actively attending individual therapy sessions, including group and family sessions.
Is attending supervised recovery programs within the community during scheduled times.
Random drug screenings during course of treatment.
Has a discharge plan already set up on the day of admission.
Continues to work on managing symptoms and is motivated to make change.

Las Vegas Recovery Center offers this level of care Typically once a covered individual no longer meets just one of these qualifications the insurance provider will no longer authorize care.

Residential Treatment Program (RTC)

This level of care is one step below Inpatient Acute Rehabilitation and has its own set of criteria. Residential Treatment is still a 24 hour structured setting, however has less medical oversite. In order to receive initial authorization and continued authorizations, clients must meet the following: Criteria:

Treatment has not been successful over the last 3 months for the individual.
Individual is having a difficult time maintaining abstinence.
Because of the individuals acute medical symptoms it would be difficult for them to maintain recovery outside of a structured environment.
Individual is not capable at this time of handling major responsibilities such as school and work.

Qualifications

Drug test are administered after any off site activities.
Individual is provided treatment with a therapist or psychiatrist.
Physical and psychiatric examination is done usually within the first 48 hours of the individual entering treatment.
Individual is attending recovery programs within the community on a daily basis.

Las Vegas Recovery Center offers this level of care Typically once a covered individual no longer meets just one of these qualifications the insurance provider will no longer authorize care. Depending on health care coverage an individual may be covered by mental health benefits but that does not mean that substance abuse benefits are offered as well.